Toxic shock syndrome in a patient with systemic lupus erythematosus.

A case is presented of toxic shock syndrome in a patient with systemic lupus erythematosus. Toxic shock syndrome is rarely reported in patients who are immunosuppressed, perhaps because such patients are often treated vigorously with antibiotics at the earliest sign of infection. The association in this case may have been coincidental.     

Toxic shock syndrome after chemical face peel

Two cases of toxic shock syndrome following chemical face peel are reported. Toxic shock syndrome is a severe toxin-mediated multisystem disease. The major signs are fever, rash, desquamation, and hypotension. It can occur in males as well as females and is not necessarily related to menstruation. The surgical wound does not usually appear infected. Early recognition is the hallmark of successful treatment. Therapy is symptomatic, with aggressive administration of fluids. Antistaphylococcal agents are used. Prophylactic antibiotics are not necessarily recommended.     

Propylthiouracil-induced hypothyroid hyperlipidemic chick: A model for clofibrate-induced toxicity

1. An animal model for clinically observed clofibrate (p-chlorophenoxy isobutyrate, CPIB)-induced toxicity has been tested.2. It is demonstrated that propylthiouracil-induced hypothyroid-hyperlipidemic chick develops severe toxic manifestations following clofibrate administration.3. Toxic symptoms are characterized by listlessness, drowziness, and extreme muscular weakness.4. This is associated with elevation of blood urea nitrogen, creatine phosphokinase, uric acid and glutamic oxaloacetic transaminase.5. Histological examination of muscle specimen from chicks exhibiting toxic syndrome showed degeneration and vacuolization of muscle fibers.6. The biochemical and histological changes observed are quite similar to those reported in clinical practice in some patients given clofibrate.7. It is suggested that this chick model could be used to investigate the biochemical basis of clofibrate toxicity.     

Toxic shock syndrome after suction lipectomy

We present a case of toxic shock syndrome with necrotizing fasciitis after suction lipectomy. The patient underwent aesthetic suction lipectomy of the abdomen, buttocks, and thighs during an office procedure by a cosmetic surgeon. On postoperative day 2, the patient was referred to the emergency department of our hospital because of pain. On admission, the patient was in toxic shock. She required intensive medical treatment for about 1 month, along with psychiatric help to adapt after the illness. Although toxic shock syndrome is a rare postoperative complication, every plastic surgeon should be acquainted with it. A combination of early recognition, diagnosis, and aggressive supportive therapy is the only successful treatment.     

Binding of type-I and type-II collagens to Staphylococcus aureus strains isolated from patients with toxic shock syndrome compared to other staphylococcal infections

Toxic shock syndrome toxin-1 (TSST-1) producing strains of Staphylococcus aureus isolated from 18 patients with toxic shock syndrome (TSS) and from 56 patients with other diagnoses were compared for capacity to interact with various serum and connective tissue proteins. TSS associated isolates showed significantly stronger binding of Type-I collagen (Cn-I) and Cn-II than non-TSS strains, in a particle agglutination assay (PAA) as well as in 125I labelled Cn uptake experiments. 125I Cn-IV binding, was similar between the two groups, whereas in PAA, a stronger interaction was observed for non-TSS than TSS associated strains. The median binding of 125I Cn to TSS-associated strains were 52.2 (Cn-I), 30.6 (Cn-II) and 20.0 (Cn-IV) compared to 20.0 (Cn-I), 14.4 (Cn-II) and 24.4 (Cn-IV) values of non-TSS strains. A saturation with 125I Cn-I and Cn-II binding was established for TSS (30 min) and non-TSS (15 min) strains. 125I Cn-IV binding reached a saturation in 10 min and 90 min with TSS and non-TSS strains respectively. Finally, the binding profiles of TSS associated and non-TSS strains to fibronectin, fibrinogen, laminin and IgG did not differ in both PAA and radioisotope assays. In scanning electron microscopy, cells of TSS associated strains bound to the reprecipitated native Cn-I fibrils. In contrast, most cells of non-TSS strains were localized to the distal end or were trapped between the Cn fibrils.(ABSTRACT TRUNCATED AT 250 WORDS)     

Binding of type-I and type-II collagens to Staphylococcus aureus strains isolated from patients with toxic shock syndrome compared to other staphylococcal infections

Abstract Toxic shock syndrome toxin-1 (TSST-1) producing strains of Staphylococcus aureus isolated from 18 patients with toxic shock syndrome (TSS) and from 56 patients with other diagnoses were compared for capacity to interact with various serum and connective tissue proteins. TSS associated isolates showed significantly stronger binding of Type-I collagen (Cn-I) and Cn-II than non-TSS strains, in a particle agglutination assay (PAA) as well as in ¹²⁵I labelled Cn uptake experiments. ¹²⁵I Cn-IV binding, was similar between the two groups, whereas in PAA, a stronger interaction was observed for non-TSS than TSS associated strains. The median binding of ¹²⁵I Cn to TSS-associated strains were 52.2 (Cn-I), 30.6 (Cn-II) and 20.0 (Cn-IV) compared to 20.0 (Cn-I), 14.4 (Cn-II) and 24.4 (Cn-IV) values of non-TSS strains. A saturation with ¹²⁵I Cn-I and Cn-II binding was established for TSS (30 min) and non-TSS (15 min) strains. ¹²⁵I Cn-IV binding reached a saturation in 10 min and 90 min with TSS and non-TSS strains respectively. Finally, the binding profiles of TSS associated and non-TSS strains to fibronectin, fibrinogen, laminin and IgG did not differ in both PAA and radioisotope assays. In scanning electron microscopy, cells of TSS associated strains bound to the reprecipitated native Cn-I fibrils. In contrast, most cells of non-TSS strains were localized to the distal end or were trapped between the Cn fibrils. The stronger interaction with Cn-I and II in particular, shown by TSS associated strains, might enhance submucosal localization, thereby facilitating entry of toxins into the blood and establishment of TSS.     

T-cell response to superantigen restimulation during menstrual toxic shock syndrome

Menstrual toxic shock syndrome (MTSS) is a severe toxin-mediated disease associated with Staphylococcus aureus producing toxic shock syndrome toxin 1 (TSST-1), a superantigen that mediates a potent activation of Vβ-2 T cells. In animal models, superantigen treatment of responsive T cells induces their initial proliferation, followed by unresponsiveness upon further superantigen stimulation. To determine whether T cell unresponsiveness occurs in humans during the acute phase of MTSS, we collected T cells from a patient with MTSS and restimulated them ex vivo with recombinant TSST-1. The expansion of T cells collected during the acute phase of disease was compared with positive controls including basal-state T cells (collected 70 days after MTSS) restimulated with TSST-1, and T cells stimulated with enterotoxin B superantigen. We found that TSST-1-induced expansion of acute phase T cells was not inferior to that observed in positive controls. We conclude that T cells were still reactive to TSST-1 during the acute phase of MTSS in this patient. As the persistence of TSST-1 production could thus be associated with further expansion of TSST-1-reactive T cells and a rapid worsening of symptoms, this study adds further support to the need for immediate eradication of the focus of infection as soon as MTSS is suspected.     

The toxic oil syndrome: An example of an exogenously induced autoimmune reaction

The toxic oil syndrome (TOS) is a chemically induced autoimmune-like reaction in humans. The etiologic agent(s) have so far not clearly been identified. A short overview is given on this disease which is associated with a unique antibody specificity to cryptic epitopes of C-reactive protein in affected patients. In addition a murine model for TOS is described which suggests that genetic suscepbility might play a role in inducing a similar syndrome in mice. These differences are reflected in the immunological alterations and cytokine production caused by the toxicant.Abbreviations CRP C-reactive protein - OAA oleic acid anilide - PAP 3-phenylamino-1,2-propanediol - TOS toxic oil syndrome     

The Refined Crystal Structure of Toxic Shock Syndrome Toxin-1 at 2.07 Å Resolution

The pyrogenic toxin toxic shock syndrome toxin-1 fromStaphylococcus aureusis a causative agent of the toxic shock syndrome disease. It belongs to a family of proteins known as superantigens that cross-link major histocompatibility class II molecules and T-cell receptors leading to the activation of a substantial number of T cells. The crystal structure of this protein has been refined to 2.07 Å with anR_crystvalue of 20.4% for 51,240 reflections. The final model contains three molecules in the asymmetric unit with good stereochemistry and a root-mean-square deviation of 0.009 Å and 1.63° from ideality for bond lengths and bond angles, respectively. The overall fold is considerably similar to that of other known microbial superantigens (staphylococcal enterotoxins). However, a detailed structural analysis shows that toxic shock syndrome toxin-1 lacks several structural features that affect its specificity for Vβ elements of the T-cell receptor and also its recognition by major histocompatibility class II molecules.     

Induction of murine hemopoietic growth factors by toxic shock syndrome toxin-1

Toxic shock syndrome toxin-1 (TSST-1), an extra-cellular 22 kDa single chain protein produced by most Staphylococcus aureus strains isolated from patients with toxic shock syndrome (TSS), induces modifications of blood cell values similar to those observed during TSS. We therefore analyzed the effects of TSST-1 on the proliferation and differentiation of murine granulocyte-macrophage progenitor cells (CFU-culture) and the eventual role of endotoxin in this response. TSST-1 had no direct effect on the proliferation of CFU-culture and was unable to influence the CSF-induced proliferation and differentiation of these progenitors. In contrast, TSST-1 was a potent inducer in spleen cell cultures of a factor with an ability to induce both colony formation by bone marrow cells and proliferation of an IL-3-dependent cell line. Nanogram amounts of TSST-1 were able to induce the release of CSF activity in spleen cell cultures from both normal and LPS-hyporesponsive mice. Cells from C3H/HeJ mice were as responsive as cells from C3H/He Pas mice. Furthermore, in spleen cell cultures from normal mice, TSST-1 and LPS did not act synergistically to induce CSF activity. Nanogram amounts of TSST-1 were also able to induce CSF activity in vivo but failed to induce IL-3 activity in the serum and organ-conditioned media from TSST-1-treated mice.     

Lethal toxin is a critical determinant of rapid mortality in rodent models of Clostridium sordellii endometritis

The toxigenic anaerobe Clostridium sordellii is an uncommon but highly lethal cause of human infection and toxic shock syndrome, yet few studies have addressed its pathogenetic mechanisms. To better characterize the microbial determinants of rapid death from infection both in vitro and in vivo studies were performed to compare a clinical strain of C. sordellii (DA-108), isolated from a patient who survived a disseminated infection unaccompanied by toxic shock syndrome, to a virulent reference strain (ATCC9714). Rodent models of endometrial and peritoneal infection with C. sordellii ATCC9714 were rapidly lethal, while infections with DA-108 were not. Extensive genetic and functional comparisons of virulence factor and toxin expression between these two bacterial strains yielded many similarities, with the noted exception that strain DA-108 lacked the tcsL gene, which encodes the large clostridial glucosyltransferase enzyme lethal toxin (TcsL). The targeted removal by immunoprecipitation of TcsL protected animals from death following injection of crude culture supernatants from strain ATCC9714. Injections of a monoclonal anti-TcsL IgG protected animals from death during C. sordellii ATCC9714 infection, suggesting that such an approach might improve the treatment of patients with C. sordellii-induced toxic shock syndrome.     

Enterococcus faecalis Inhibits Superantigen Toxic Shock Syndrome Toxin-1-Induced Interleukin-8 from Human Vaginal Epithelial Cells through Tetramic Acids

The vaginal mucosa can be colonized by many bacteria including commensal organisms and potential pathogens, such as Staphylococcus aureus. Some strains of S. aureus produce the superantigen toxic shock syndrome toxin-1, which can penetrate the vaginal epithelium to cause toxic shock syndrome. We have observed that a female was mono-colonized with Enterococcus faecalis vaginally as tested in aerobic culture, even upon repeated culture for six months, suggesting this organism was negatively influencing colonization by other bacteria. In recent studies, we demonstrated an “outside-in” mechanism of cytokine signaling and consequent inflammation that facilitates the ability of potential pathogens to initiate infection from mucosal surfaces. Thus, we hypothesized that this strain of E. faecalis may make anti-inflammatory factors which block disease progression of more pathogenic organisms. E. faecalis MN1 inhibited interleukin-8 production from human vaginal epithelial cells in response to the vaginal pathogens Candida albicans, Gardnerella vaginalis, and Neisseria gonorrhoeae, as well as to toxic shock syndrome toxin-1. We further demonstrated that this organism secretes two tetramic acid compounds which appear responsible for inhibition of interleukin-8 production, as well as inhibition of T cell proliferation due to toxic shock syndrome toxin-1. Microbicides that include anti-inflammatory molecules, such as these tetramic acid compounds naturally produced by E. faecalis MN1, may be useful in prevention of diseases that develop from vaginal infections.     

Th1 and Th2 cytokines in a self-healing primary pulmonary Aspergillus flavus infection in BALB/c mice

Some patients with Group A Streptococcal toxic shock syndrome (StrepTSS) develop a unique form of cardiomyopathy characterized by global hypokinesia and reduced cardiac index. Here we investigated the immune responses of cardiomyocytes to Group A Streptococcus both in vivo and in vitro. Our data demonstrate that cardiomyocyte-derived cytokines are produced following both direct GAS stimulation and after exposure to GAS-activated inflammatory cells. These locally produced, cardiomyocyte-derived cytokines may mediate cardiac contractile dysfunction observed in patients with StrepTSS-associated cardiomyopathy and may hold the key to our ability to attenuate this severe complication.     

Toxic shock syndrome: clinical and laboratory findings in 30 patients.

Thirty patients with toxic shock syndrome (TSS) that developed between May 1980 and March 1983 in Vancouver were studied prospectively. In the 15 cases related to menstruation the illness followed a uniform and predictable clinical course. In the 15 other cases (3 in males) the disease was not related to menstruation, and the sources of the Staphylococcus aureus infections were diverse; 67% were hospital-acquired. Profound but transient lymphocytopenia associated with marked leukocytosis was the most striking laboratory finding and one not previously emphasized in the literature. S. aureus was isolated from sites of soft-tissue infection, the vagina or the endocervix in all except one case. Two patients had bacteremia. Phage types 29 and 29 + predominated among the isolates tested. All the genital S. aureus isolates tested produced the TSS marker protein, while the bacteria from wounds, throat, nose and blood were sometimes positive. Two patients (7%) died from refractory shock and multiple organ failure. All patients with a febrile, exanthematous, multisystem illness, particularly if it is associated with menstruation or a staphylococcal infection, should be evaluated promptly and treated empirically for TSS.     

Study on the pathogenesis of pathophysiological changes of burn systemic infection

The present prospective study showed that incidence of systemic infection in severe burn patients was 30.9%. Toxic shock and multiple organ failure (MOF) developed in all patients with uncontrolled systemic infection. Both morbidity and mortality of MOF were 76.5%. In the infection group, plasma TXB(2) and TXB(2)/6-keto-PGF(1alpha) ratio increased markedly. Their changes were closely correlated with the clinical course and deterioration of systemic infection. Circulatory platelet aggregate ratio decreased significantly, while myocardiac enzyme spectrum greatly increased. Thrombi were observed in visceral tissues from patients dying of systemic infection. These suggested that TXA(2)/PGI(2). imbalance promoting microaggregate and thrombus formation may be one of the pathogenic effects of toxic shock and MOF in burn patients.     

Invasive infection caused Streptococcus group A and streptococcal toxic shock syndrome

Modern data on the etiology and pathogenesis of invasive streptococcal infection and the syndrome of streptococcal toxic shock are presented. In the course of the last 10-15 years essential changes in the system of interaction of group A streptococci and the macroorganism have been noted. The growth of morbidity in severe invasive forms of streptococcal infection with different clinical manifestations, including the syndrome of toxic shock, is observed. Most often this disease develops in elderly people, making up a group of risk, but sometimes affects healthy young people. Different pathogenicity factors of streptococci, capable of inducing the development of infection, are analyzed. Special attention is given to superantigens: pyrogenic toxins and M-protein. The suggestion that the development of the disease is seemingly linked with the state of specific protective immunity is substantiated. In spite of achievements in the field of the microbiology and immunology of group A streptococci, the causes of the appearance and development of invasive streptococcal infection have not yet been determined.     

Specific immuno capturing of the Staphylococcal superantigen toxic‐shock syndrome toxin‐1 in plasma

Toxic‐shock syndrome is primarily caused by the Toxic‐shock syndrome toxin 1 (TSST‐1), which is secreted by the Gram‐positive bacterium Staphylococcus aureus. The toxin belongs to a family of superantigens (SAgs) which exhibit several shared biological properties, including the induction of massive cytokine release and V_β‐specific T‐cell proliferation. In this study we explored the possibility to use monoclonal Variable domains of Llama Heavy‐chain antibodies (VHH) in the immuno capturing of TSST‐1 from plasma. Data is presented that the selected VHHs are highly specific for TSST‐1 and can be efficiently produced in large amounts in yeast. In view of affinity chromatography, the VHHs are easily coupled to beads, and are able to deplete TSST‐1 from plasma at very low, for example, pathologically relevant, concentrations. When spiked with 4 ng/mL TSST‐1 more than 96% of TSST‐1 was depleted from pig plasma. These data pave the way to further explore application of high‐affinity columns in the specific immuno depletion of SAgs in experimental sepsis models and in sepsis in humans. Biotechnol. Bioeng. 2009; 104: 143–151 © 2009 Wiley Periodicals, Inc.     

Toxic shock syndrome toxin 1 (TSST-1) production by staphylococci isolated from goats and presence of specific antibodies to TSST-1 in serum and milk.

The ability of staphylococcal strains isolated from different anatomical sites in 133 healthy goats to produce toxic shock syndrome toxin 1 (TSST-1) and the presence of antibodies to this toxin in serum and milk were studied. The enzyme-linked immunosorbent assay method was used to detect both the toxin and the presence of antibodies. Of a total of 342 staphylococcal strains studied, 86 (25.2%) were found to produce TSST-1. Specific antibodies to TSST-1 were found in the serum of 57 (42.9%) of the animals studied and the milk of 63 (47.4%) of the animals. These results suggest that goats are frequently in contact with staphylococci that produce TSST-1, a toxin usually associated with Staphylococcus aureus strains isolated from cases of toxic shock syndrome in humans.     

Toxic shock syndrome toxin 1 (TSST-1) production by staphylococci isolated from goats and presence of specific antibodies to TSST-1 in serum and milk

The ability of staphylococcal strains isolated from different anatomical sites in 133 healthy goats to produce toxic shock syndrome toxin 1 (TSST-1) and the presence of antibodies to this toxin in serum and milk were studied. The enzyme-linked immunosorbent assay method was used to detect both the toxin and the presence of antibodies. Of a total of 342 staphylococcal strains studied, 86 (25.2%) were found to produce TSST-1. Specific antibodies to TSST-1 were found in the serum of 57 (42.9%) of the animals studied and the milk of 63 (47.4%) of the animals. These results suggest that goats are frequently in contact with staphylococci that produce TSST-1, a toxin usually associated with Staphylococcus aureus strains isolated from cases of toxic shock syndrome in humans.